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Purpose: To describe the events that occurred on 1 July 1993 when a man entered a high-rise office tower in downtown San Francisco armed with semi-automatic handguns. Traveling through four floors of the 48-story building, the assailant shot 14 people before turning the gun on himself. Methods: Debriefings and interviews were performed with prehospital care providers, managers, dispatchers, trauma and emergency department physicians and staff, and police and fire personnel. Results: This multiple casualty incident (MCI) avoided the usual lack of central coordination that often impedes effective dispersal of victims to definitive care in a timely manner. However, communications problems secondary to radio reception voids as well as structural and logistical challenges related to the vertically oriented tactical situation were identified and reviewed. Conclusion: This event and its management provided a real-life test of the city's prehospital MCI plan as well as a test of the city's sole trauma center's and emergency department readiness to handle a MCI. The implications for prehospital disaster planning and trauma/emergency services was presented.

A botulism-induced mass casualty incident has the potential to severely compromise a community's healthcare infrastructure, based upon its lethality, rare occurrence, and duration of symptoms, which require extensive support and care. Although early recognition and treatment with antitoxin or botulism immunoglobulin are essential to the effective management of this type of an incident, the two major challenges in recognition and treatment are the hundreds, if not thousands, of casualties or potential casualties requiring rapid screening and the fact that most clinicians remain ignorant of the management of botulism. The purpose of this article is to present the Botulism Questionnaire, which will assist with the screening of casualties, provide educational and diagnostic cues for clinicians and the lay public, and create a layer of protection for the health-care infrastructure. The applications of this questionnaire in various formats, the numerous points of distribution, and the variety of platforms from which it can be launched will be explored. Key wordsbotulism, botulism diagnosis, botulism poisoning, Botulism Questionnaire, botulinum toxin. CHALLENGES ASSOCIATED WITH BOTULISMWhen contemplating the immense time-sensitive challenges that clinicians encounter in the management of a botulisminduced mass casualty incident (MCI), it would be remiss not to mention several crucial facts that would further compound these challenges. Botulinum toxin is the most lethal toxin known to humans (Arnon et al., 2001;Timmons & Carbone, 2005). The natural occurrence of botulism is extremely rare (Stewart, 2001;Horowitz, 2005). Terrorist states and organizations attempting to perpetrate attacks using botulinum toxin to date have been, to our good fortune, unsuccessful (Arnon et al., 2001;Stewart, 2001). Clinicians, and the healthcare infrastructure as a whole, have limited awareness and even more limited experience in the recognition and management of casualties of botulism (Pesik et al., 1999;Richards et al., 1999;Rebmann & Mohr, 2008). Also, the lay public has an immediate need for clear, concise, and actionable information that it can process and act upon (Glik et al., 2004;. One answer to these pressing issues was the development of a unique, user-friendly, and zero-cost solution: the Botulism Questionnaire (Appendix I), developed by Rega et al. (2007).The Botulism Questionnaire offers a user-friendly approach to providing education and enhancing both clinicians' and the lay public's ability to recognize and manage a botulism-induced MCI. The potential number of casualties that could be generated by an intentional contamination of food or beverages with botulinum toxin conceivably could reach the hundreds of thousands (Wein & Liu, 2005). Thus, any tool that offers some screening capability has the potential to minimize the sheer volume of individuals that could present to hospital emergency departments (EDs). METHODS AND PROCESSThe Botulism Questionnaire was developed to be used as a screening tool by all responders...